from review to action -...

From Review to Action

Building U.S. Capacity to Review and Prevent Maternal Deaths

Julie Zaharatos Nicole Davis Emily Johnston

CDC Foundation CDC Division of Reproductive Health

2

• Overview of maternal mortality in the U.S.

• Steps to establishing a maternal mortality review committee (MMRC)

• Results of Report from Nine Maternal Mortality Review Committees

• Moving MMRC data to action

• State-based Perinatal Quality Collaboratives:a growing movement to improve perinatal health

Outline

4

CDC – National Center for Health

Statistics (NCHS)

CDC – Pregnancy Mortality

Surveillance System (PMSS)

Data Source Death certificatesDeath certificates linked to fetal death

and birth certificates

Death certificates linked to fetal death

and birth certificates, medical

records, social service records,

autopsy, informant interviews…

Time Frame During pregnancy – 42 days During pregnancy – 365 days During pregnancy – 365 days

Source of

ClassificationICD-10 codes Medical epidemiologists (PMSS-MM) Multidisciplinary committees

Terms Maternal death

Pregnancy associated,

(Associated and) Pregnancy related,

(Associated but) Not pregnancy

related




related

MeasureMaternal Mortality Rate - # of Maternal

Deaths per 100,000 live births

Pregnancy Related Mortality Ratio - #

of Pregnancy Related Deaths per

100,000 live births



100,000 live births

PurposeShow national trends and provide a

basis for international comparison

Analyze clinical factors associated

with deaths, publish information that

may lead to prevention strategies

Understand medical and non-

medical contributors to deaths,

prioritize interventions that

effectively reduce maternal deaths

Nicely reviewed in:

• St. Pierre, et al. 2018. Challenges and Opportunities in Identifying, Reviewing, and Preventing Maternal Deaths. Obstetrics & Gynecology. 131: 1: 138-142.

• Callaghan, William M. 2012. Overview of maternal mortality in the United States. Seminars in perinatology. 36; 1: 2-6.

• Berg C, et al. (Editors). Strategies to reduce pregnancy-related deaths: from identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001

Maternal Mortality Review

Committees

Data

5http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

Challenge: Trends

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

6

0

10

20

30

40

50

60

<12 12 13-15 16+

PR

MR

(D

eat

hs

pe

r 1

00

,00

0 b

irth

s)

Years of Education

Pregnancy-Related Mortality Ratio, 2011-2013by Race-Ethnicity and Education

NHW NHB HispanicNon-Hispanic White

Non-Hispanic Black

Challenge: Equity

7

Poverty

Chronic stress

Social support

Perceived discrimination

Access to health care

Quality of health careNeighborhood

deprivation

Social determinants of women’s morbidity & mortality?

From Michael Kramer at Emory University

8

CDC – National Center for Health

Statistics (NCHS)

CDC – Pregnancy Mortality

Surveillance System (PMSS)

Data Source Death certificatesDeath certificates linked to fetal death

and birth certificates

Death certificates linked to fetal death

and birth certificates, medical

records, social service records,

autopsy, informant interviews…

Time Frame During pregnancy – 42 days During pregnancy – 365 days During pregnancy – 365 days

Source of

ClassificationICD-10 codes Medical epidemiologists (PMSS-MM) Multidisciplinary committees

Terms Maternal death




related




related

MeasureMaternal Mortality Rate - # of Maternal

Deaths per 100,000 live births



100,000 live births



100,000 live births

PurposeShow national trends and provide a

basis for international comparison

Analyze clinical factors associated

with deaths, publish information that

may lead to prevention strategies

Understand medical and non-

medical contributors to deaths,

prioritize interventions that

effectively reduce maternal deaths

Nicely reviewed in:

• St. Pierre, et al. 2018. Challenges and Opportunities in Identifying, Reviewing, and Preventing Maternal Deaths. Obstetrics & Gynecology. 131: 1: 138-142.

• Callaghan, William M. 2012. Overview of maternal mortality in the United States. Seminars in perinatology. 36; 1: 2-6.

• Berg C, et al. (Editors). Strategies to reduce pregnancy-related deaths: from identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001

Maternal Mortality Review

Committees

Unique Role of MMRCs

9

WA

OR

CA

MT

ID

NV

AZ

UT

WY

CO

NM

TX

OK

KS

NE

SD

ND

MN

IA

MO

AR

LA

MSAL

GA

FL

SCTN

NC

IL

WIMI

OH

IN

KY

WV VA

PA

NY

ME

VT

NH

NJ

DE

MD

Washington D.C.

MA

CT

RI

AK

HI

New York City

Opportunity: MMRCs

Existing Review

Planning a review

Unknown / No review

PR

Philadelphia

10

What is a Fully Functional Review Committee?

It has required authority and protections

It has defined stakeholders and multidisciplinary

membership

It has a defined purpose, mission, vision, and scope

It has processes that are established and documented

It uses data to develop information

It translates information/recommendations to action

(directly/indirectly)

MMRC Checklist

11

Everyone has a role to play!

• State leadership

• Public health

• Host agency

• Professional membership organizations

• Consumer advocacy

• Perinatal Quality Collaborative

…and more

MMRC Partners

12

MMRC Logic Model

13

MMRC Logic Model

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• Systematic data collection and use

Maternal Mortality Review Information Application (MMRIA)

• Technical assistance and training

In-person and distance-based, conferences

• Access to resources and learning

www.ReviewtoAction.org

Strategies

http://www.reviewtoaction.org/

15

WA

OR

CA

MT

ID

NV

AZ

UT

WY

CO

NM

TX

OK

KS

NE

SD

ND

MN

IA

MO

AR

LA

MSAL

GA

FL

SCTN

NC

IL

WIMI

OH

IN

KY

WV VA

PA

NY

ME

VTNH

NJDE

MD

Washington D.C.

MA

CT

RI

AK

HI

New York City

A Common Language

Authority and Protection

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1. Authority to access data

MMRC Authority & Protections

18


2. Confidentiality and protection of collected data,

proceedings and activities


19




3. Immunity for committee members


20





4. Regular reporting and dissemination of findings


21





4. Regular reporting and dissemination of findings

5. Multidisciplinary committee with local input


22

Deaths

Near Misses

Severe Maternal Morbidity

Maternal Morbidity Requiring Hospitalization

Maternal Morbidity Resulting in Emergency Department Visit

Maternal Morbidity Resulting in Primary Care Visit

Power of MMRCs

Eliminate preventable

maternal deaths

Reduce maternal morbidity

Improve population health of women

Report from Nine Maternal Mortality

Review Committees

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Report from Nine Maternal Mortality Review Committees

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The Data

• 9 Committees

• 855 potentially pregnancy-related deaths

• 680 valid pregnancy-associated deaths for which

pregnancy-relatedness could be determined

• 237 pregnancy-related deaths

Was the Death Pregnancy-Related?

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Distribution of Pregnancy-Related Deaths by Timing of Death in Relation to Pregnancy

What was the Cause of Death?

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Leading Underlying Causes of Pregnancy-Related Deaths

Was the Death Preventable?

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Distribution of Preventability Among Pregnancy-Related Deaths

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Distribution of Preventability Among Pregnancy-Related Deaths,

by Cause of Death

What were the Factors that

Contributed to this Death?

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Distribution of Contributing Factors among Pregnancy-Related Deaths

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Contributing Factors

Cause of Death Community Facility ProviderPatient/Family

Systems of Care

Total Factors

Pregnancy-related deaths*

Factors per death

Cardiovascular & Coronary Conditions

Count of Factors 6 12 26 51 25 120 28 4.3

% of cause-specific factors 5.0 10.0 21.7 42.5 20.8

Hemorrhage

Count of Factors 0 7 31 26 36 100 27 3.7

% of cause-specific factors 7.0 31.0 26.0 36.0Infection

Count of Factors 1 1 36 30 20 88 21 4.2


Cardiomyopathy

Count of Factors 0 1 24 31 11 67 16 4.2

% of cause-specific factors 1.7 41.4 43.1 13.8

Embolism

Count of Factors 0 0 5 15 3 23 14 1.6

% of cause-specific factors 21.7 65.2 13.0

Mental Health Conditions

Count of Factors 5 3 24 37 19 88 14 6.3


Pre-eclampsia & Eclampsia

Count of Factors 2 2 29 13 10 56 11 5.1


Total 14 26 175 203 124 542 131 4.1

*Pregnancy-related deaths that had at least one critical factor identified. Critical factors from at least 7 pregnancy-related deaths included in the 2017 report are not represented here due to changes in data formatting.

Contributing factor level by leading causes of pregnancy-related death

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Hemorrhage

Factor Level(% of total factors)

Most Common Factor Class(es)(% of level-specific classes)

Common Themes

Provider Assessment Delayed or missed diagnosis or treatment

(31.0%) (33.3%) Ineffective treatments

Knowledge Failure to seek consultation

(13.3%)

Systems of Care Personnel Inadequate training

(36.0%) (27.8%) Inadequate or unavailable personnel

Policies/Procedures Lack of applicable policies and procedures

(19.4%)

Continuity of Care/Care Coordination(16.7%)

Lack of coordination and communication between providers that supports patient management

Contributing factors by leading causes of pregnancy-related death

What are the recommendations

and actions that address those

contributing factors?

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Recommendation themes:

Improve training

Enforce policies and procedures

Adopt maternal levels of care/ensure appropriate level of care determination

Improve access to care

Improve patient/provider communication

Improve patient management for mental health conditions

Improve procedures related to communication and coordination between providers

Improve standards regarding assessment, diagnosis and treatment decisions

Improve policies related to patient management, communication and coordination between providers, and language translation

Improve policies regarding prevention initiatives, including screening procedures and substance use prevention or treatment programs

What is the Anticipated Impact of

Those Actions if Implemented?

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Anticipated Potential for Impact of Actions if

Implemented

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Emerging Issues

• Maternal Mental Health Conditions – an Update

• Severe Maternal Morbidity Review

• Incorporating Equity – an Update

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We wish you were here!

Moving MMRC Data to Action

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MMRC actions take many forms. A few examples…

Actions

45

Data

National Center for Chronic Disease Prevention and Health Promotion

State-based Perinatal Quality Collaboratives:A Growing Movement to Improve Perinatal Health

Perinatal Quality Collaboratives (PQCs)

Multidisciplinary networks working together to improve maternal and infant outcomes

Evidence-informed clinical practices and processes through continuous quality improvement

PQCs include key leaders in private, public, and academic health care settings

Ultimate goal = improvements in population-level outcomes in maternal and infant health

Resources to Support PQCs

CDC PQC website https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pqc.htm

• PQC Resource Guide

• CDC – Perinatal Quality Collaboratives Webinar Series

National Network of Perinatal Quality Collaboratives (NNPQC)

• NNPQC Collaboratory https://nnpqc.community.nichq.org/

• Webinars available to all state PQCs

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pqc.htm

https://nnpqc.community.nichq.org/

Obstetric/Maternal PQC Initiatives

Reduction of non-medically indicated deliveries <39 weeks gestation

Progesterone for prevention of preterm birth

Appropriate use of antenatal steroids

Improve response to and management of obstetric hemorrhage

Improve response to and management of hypertensive disorders of pregnancy

Maternal substance use disorder

Reduction of unnecessary cesarean deliveries

Postpartum long-acting reversible contraception (LARC)

Contact Us!

Nicole Davis

[email protected]

Emily Johnston

[email protected]

Julie Zaharatos

[email protected]

mailto:[email protected]



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